Authors :
Presenting Author: Katherine Xiong, MD – Stanford University
Prathyusha Teeyagura, MSBI – Research Data Analyst, Neurology, Stanford University; Amelia Sperber, MSN, RN, CNS, CPNP-PC – Pediatric Neuroscience Clinical Nurse Specialist, Stanford Children's Health; Courtney Wusthoff, MD – Child Neurology – Stanford University; William Gallentine, DO – Child Neurology – Stanford University
Rationale:
Status epilepticus (SE) is associated with long-term consequences such as cognitive impairment, irreversible brain injury, and death. Delays in administration of anti-seizure medications (ASM) during SE treatment occur frequently, but appropriate utilization of SE pathways can improve timing of ASM administration. Lucille Packard Children’s Hospital-Stanford (LPCH-S) implemented a SE clinical pathway in June of 2019. The first edition was distributed electronically without formal education to nursing and MD staff until the second edition was published in 8/2020. Initial retrospective data capture was limited by insufficient documentation of seizures in the electronic medical record (EMR), prompting Plan-Do-Study-Act (PDSA) Cycle 1 (PC1) from August 2020 through March 2021 directed to improve documentation. Adequate documentation was achieved by April 2021. The primary aim was to increase total adherence to the SE clinical pathway. The secondary aims were to improve the rate of correct dosing of BZD to 100% and increase the percentage of patients with goal time to BZD Dose 1 (< 6 minutes from seizure detection) to > 70%.
Methods:
Pre-intervention period was from March 2019 to March 2021, after the second pathway edition and PC1 were implemented. Post-intervention period was from April 2021 through May 2023, and two PDSA cycles were conducted (Figure 1). PDSA Cycle 2 (PC2) included RN and MD pathway education implemented from April 2021 through September 2022. During PDSA Cycle 3 (PC3), from October 2022 through May 2023, a SE Order Set was integrated into the EMR. Standard descriptive statistics were used to assess pathway adherence and the proportion of patients receiving the correct BZD dosage and goal time to BZD dose (Dose 1: < 6 minutes of documented seizure detection, Dose 2: < 5 min from BZD Dose 1) pre- and post-PDSA cycles. Descriptive statistics utilizing medians with interquartile ranges were used to characterize the timing of ASM administration in each group.
Results:
Pre-intervention, SE pathway adherence was 18%. Post-PC2, adherence improved to 40%, and increased to 50% Post-PC3 (Table 1). The first BZD dosage was correct in 75% pre-intervention, 74% post-PC2, and increased to 83% post-PC3. Rate of correct second BZD dosages increased to 92% pre-intervention, 86% post-PC2, and 100% post-PC3.
Pre-intervention, time to BZD Dose 1 was in goal for 50% of patients. Post-PC2, this improved to 71%, and to 86% post-PC3. Correct time to BZD Dose 2 increased from 31% pre-intervention to 60% post-PC3. There was also a decrease in the median time (in minutes) to second line ASM from 19 (9,28) pre-intervention, to 12 (6,21) post-PC2, and 7 (6,15) post-PC3. Of note, median time (in minutes) to BZD Dose 1 decreased in PC3 to 3 (2.5,5) compared to 4.5 [2,9.25] pre-intervention and 5 [2.75,7.25] post-PC2, suggesting efforts to promote rapid administration of BZD may have inadvertently led to BZD administration prior to 5 minutes of seizure duration.
Conclusions:
An institutional SE pathway can facilitate correct and rapid administration of first and second line ASM. Successful adherence to a SE pathway requires multi-disciplinary interventions and continued education. Integration of the SE pathway into EMR order sets can support adherence.
Funding: No funding received.